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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 6 of 6 Results
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
Costello WG, Zhang L, Schnipper JL, et al. J Racial Ethn Health Disparities. 2021;8:438-447.
This study recruited nearly 600 African-American and Caucasian patients discharged home from an urban community hospital to identify differences in the incidence of adverse events (AEs) within 30 days of discharge. The authors found that approximately 30% of both groups of patients experienced a post-discharge AE; there was no statistically significant difference in incidence by race.
Tsilimingras D, Schnipper JL, Duke A, et al. J Gen Intern Med. 2015;30:1164-71.
The period following hospitalization is known to carry high risk for adverse events. Investigators found that more than one-quarter of participants experienced an adverse event after discharge, raising concerns that post-hospitalization adverse events have persisted despite interventions directed at enhancing hospital-to-home care transitions.
Romano PS, Mull HJ, Rivard PE, et al. Health Serv Res. 2009;44:182-204.
The AHRQ Patient Safety Indicators (PSIs) were originally developed as a means of screening administrative data to identify potential patient safety problems. However, they are increasingly being used for quality measurement and hospital comparison purposes. This study sought to evaluate the accuracy of surgical PSIs for identification of true safety issues, by comparing PSI-detected events to clinical data. The PSIs tested had only moderate sensitivity and specificity for detecting clinical adverse events, lending support to prior research, which concluded that PSIs should be used only for screening purposes. An AHRQ WebM&M commentary discusses the limitations of using PSIs for public reporting and hospital comparison purposes.
Tsilimingras D. Jt Comm J Qual Patient Saf. 2008;34:85-97.
This review examined the literature on postdischarge safety and discontinuities in care. The authors identify common types of postdischarge adverse events and provide constructive recommendations to improve safety after hospitalization.